Monday, September 26, 2011

Post Polio Survivors: Role Models of Overcoming Adversity

Saturday, September 24, 2011, was the 25th anniversary of the Post Polio Support Group of Maine, and I was honored to be an invited speaker at the celebration. Upon my arrival, Ann Crocker, one of the meeting organizers said: "there's not too many of us left." She was referring to the fact that many polio survivors who were children or young adults in the late 1940's and 50's when the polio epidemic struck the United States, are now in their late 60's and 70's. Many of these individuals have lived a life time with mild to moderate disability resulting from the intitial experience with polio, and now face some further decline in physical function as a consequence of age related changes as well as what are referred to as "late effect polio" or post-polio syndrome. (PPS)

Post Polio Syndrome typically refers to problems which emerge many years after contracting the original virus, and may include symptoms such as: fatigue, pains in muscles and joints, and new muscle weakness. Muscle weakness can include the respiratory and bulbar system ( head and neck) with a subsequent affect on voice and swallowing. I discussed some of these changes with attendees, advising they report any decline in voice and swallowing to their physician, and request a consult with a qualified speech-language pathologist for further evaluation and instruction in exercises or techniques which may reduce symptom impact.

I can remember, lining up outside the local high school when I was a child to receive my sugar cube of prevention against the polio virus, but my first introduction to life after polio came at the age of 16, when I responded to an advertisement in the newspaper to care for a disabled woman. Susan Armbrecht was in her mid 20's when I met her, but she was no larger than the size of a child, her skeletal muscles having been halted in growth at the age of 6yrs when she contracted the  polio virus. The first night of sleep at Susan's house, resulted in no sleep, as I listened to the "woosh" of her iron lung, and responded to her periodic calling me for a position change. I lay there that night, strategizing about how I could ease out of this newly formed agreement. But, after a few more weekends with Susan, her spirit and enthusiasm for life had overtaken me, and we began a life-long friendship, until her passing a couple of years ago, just shy of her 70th birthday. It was through Susan that I had the honor of meeting Gini Laurie, the founder of the Toomey Gazette, later named the Rehabilitation Gazette, and predecessor of Post Polio Health International. Gini is also credited as being one of the originators of the Independent Living Movement, a movement which raised consciousness about what it means to be a person living with a disability, helping to banish words such as: "crippled", and fostering the notion that a person living with a disability is best positioned to inform the non-disabled about what they need to live life fully.

Gini Laurie also articulated what polio survivors needed saying: "it was apparent they had two vital needs:  people and information. They wanted to keep [up] with each other , and wanted to share information about their lives and equipment."

This past weekend's conference affirmed that these two vital needs are still relevent and being provided for by support groups, like the one in Maine.  I hope that I contributed to the participant's learning needs with the information and education I provided, but, as is often the case anymore, I feel that I left the meeting also enriched by my interraction with the group members.

Since returning home, I have been thinking alot about two life-long friends affected by polio, Susan and my friend Mickie McGraw, a nationally known art therapist, both who lived and live life with zest. I am thinking that their zest for life is also a result of having survived a catastrophic illness, because I heard it reflected in the voices and stories from a  few of Saturday's attendees. Howard, who despite loss of neck and shoulder muscles on the right side of his body, went on to join the military, and proudly told me how he managed to carry his rifle. Reggie whose big heart was evident and practically bursting our of his shirt as he introduced a Maine legislator and her proclamation.

Many of the people in attendance have compensated most of their lives for weakness or muscle loss in one part of their body or another. But what I did not hear was one murmur of self-pity. Maybe it was the post-war timing of the illness or the fact that many were young children, but all seemed to have just gotten on with their lives. The effect, and now late effect of polio is certainly relevent, but for most it seems to have been integrated as a part of their descriptive adjectives, like tall or short, but not the defining one.

The motto of the polio surviviors is: "we're still here". I felt  and saw that clearly on Saturday. Not only are they here, but they give witness to the fact that people can have full lives, lives which might include varying levels of disability, but they do not need to be defined by it.

For more information about Post Polio Health, please visit:

http://www.post-polio.org/

Sunday, September 11, 2011

Parkinson's And Your Voice: I Can't Get No Satisfaction

I can't get no satisfaction
I can't get no satisfaction
'Cause I try and I try and I try and I try
I can't get no, I can't get no

I Can't Get No) Satisfaction lyricsSongwriters: Jagger, Mick; Richards, Keith;

Have you sometimes felt dissatisfied after leaving therapy? Voice sounds great while you're with the therapist, and minutes later while conversing with your spouse, the chorus begins: "What did you say?"

From your spouse's point of view, who minutes ago heard you speaking louder and clearer, it may now appear that you are: " just not trying hard enough," "you're lazy", "you're not motivated," or the assortment of other complaints I often hear. In the meantime, you hang your head in shame and semi-resolve that maybe you can't make these changes that are being demanded of you, and whisper: "I'll try".

 So why is it so hard to retain the improvements in speech and voice when on your own?

There is probably no one answer that fits everyone, but a few possibilities include: you can't remember what to do, you can't focus on your speech and your thoughts at the same time, it doesn't feel natural to be speaking differently than you are now accustomed, you haven't yet created a new habit, and so on. Thirty days of voice treatment may simply not be enough time to change a voice habit that has been established over several years, and that is now shaped by a voice instrument not so easily played.

One of the biggest hurdles for most of my patients with voice changes from Parkinson's disease is making the transition from a treatment/therapy setting to everyday use of their voice. The same patient who can register 80dB on the sound level meter when in treatment, may barely be heard above the background noise of the car engine on the drive home.

I often tell me patients that voice practice is like going to the driving range to improve your golf game. It may help you to hit the ball harder and further, but if you never actually get on a golf course and play, you will never really be able to master  the varying terrain and obstacles of a golf course. Similarly, if you diligently do your 30 minutes or so of voice practice every morning after breakfast while sitting at the kitchen table, but then don't talk again until dinner, it is unlikely that you will implement the change you desire.

Daily communication takes us over many varying terrain. We converse with familiar and unfamiliar people, in quiet and noisy environments, in settings where we may feel hurried or pressured to speak, on cell phones, in the car, and some of us,  even in our sleep! Before your diagnosis of Parkinson's and before you developed changes in your voice and speech you likely never gave much thought to all of this. Your voice, like the rest of your body was operating in automatic mode, and you easily made those shifts in voice from conversational with your friends, to loud at the ballpark, and quiet in the movie theatre.

Creating daily opportunities to converse with familiar and unfamiliar people in an out of your home is going to be an important aspect of your overall improvement. All the speech therapy in the world will be of little benefit if you sit home watching TV all day. Joining a group that centers around an interest you may have, such as photography or bridge may help you stay motivated. Even walking around the mall, talking to various retail personnel will provide you with real world practice. 

Upon completion of voice therapy , a patient of mine asked: "do I have to keep doing these exercises forever?" My short answer, "yes". As long as Parkinson's is lurking around in the background of your life, you must continue to do some daily voice practice, but, more importantly, stay engaged in life by communicating with those around you.



Sunday, September 4, 2011

Parkinson's And Your Voice: Don't Give Me That Tone Of Voice!

I had an interesting experience the other day  that reminded me of the difference between voice volume ( loudness) and tone ( shouting), a distinction I try to make for patients who are trying to improve their speech and voice, particularly if they have already received some feedback from their spouse that their attempts to be louder are being perceived  as "bossy". My male patients, in particular, can have a little trouble with this distinction.

I made a phone call to a gentleman at a University in Ft. Myers. I was referred to this man by a business advisor I work with, and had hoped to receive some specific advice with a project. However, before I barely got "hello" out of my mouth, the voice on the other end of the phone began" barking" questions at me. I was so taken aback, that I asked: "why are you shouting at me?" Seemingly unfazed by my question, he continued with his aggressive tone, until I finally suggested that we end the call and follow-up with an email.

This five minute phone interchange was a great example of how we are always responding to the tone of voice along with the message of the words. In fact, I was so distracted and unsettled by the tone in this instance, I really couldn't process the questions or the statements very well. The "tone" of authority may have it's place in boot camp but it did not have a place in a business call. The tone of someone's voice is often what evokes a particular emotional response from us, and as in my example above, can sometimes cause us to misinterpret the message or dislike the messenger.

Want to check your tone of voice? Below is a fun little exercise I did recently at a Parkinson's retreat. Try repeating the statement: "I am really happy to be here today," while varying the tone as if you were actually making a different statement. Notice the difference between an angry, happy, and disappointed tone. Blue is what you say, and red is what you mean.

"I'm really happy to be here today" (That jerk just backed into my car)

"I'm really happy to be here today" (I just won a million dollars}

"I'm really happy to be here today" (Our trip to the Bahamas was cancelled)

If  being louder is one of your personal goals, try noticing your tone this week. Tone of voice often reflects our mood and emotional state, and is the subtle nuance of our voice that makes a listener ask: "what's wrong?" "what are you so happy about?", etc. What is your tone communicating?

If loudness is your goal, another exercise you might try is "placing" your voice in different locations. By that, I mean, choose different spots in the room you are in and direct your vocal energy to that spot. You will likely notice that without alot of effort, as the distance grows further, you become louder.

Have Fun...and I MEAN IT!

Saturday, September 3, 2011

Therapy Following Stroke: Advocating For Treatment

Several weeks ago I posted about my aunt, who suffered a hemorrhagic stroke mid-July, leaving her with a right sided paralysis, along with some mild speech and swallowing problems. Although she was said to have had a large stroke, and she is in her 80's, when I visited with her in ICU shortly after the onset, I was pleasantly surprised to see that she was already eating and speaking, both good prognostic indicators so soon after acute stroke.
Following her one week stay in the hospital she was transferred to a subacute rehabilitation setting in a suburb of Cleveland, where she lives.

My cousin has emailed periodic updates, and although she expresses the expected "overwhelm" of a family member suddenly thrust into this new world of rehabilitation, she has sounded cautiously optimistic, that is, until this week. In an email she states: "the nursing home told us that they evaluated Mom today and they feel she has hit a plateau, so as of Friday 9/9, her therapy will come to an end. We were told originally, she would have 100 days paid thru Medicare if she showed improvement. She is doing way more than I ever expected she would be able to do...but apparently it isn't enough in their evaluation."

Plateau, I have always hated that word. What does it mean?How is it being determined, and Who is making that determination?

"The patient has hit a  plateau" is often used by therapists to refer to a period in treatment when an individual fails to continue to make any measurable progress, and hence, used as justification to discharge from  therapyI am quite certain that 6 weeks following an acute stroke my aunt has NOT hit a plateau as she is barely out of the acute phase of recovery. In fact, studies looking at motor recovery following stroke have found that the most dramatic improvements occur in the first 30 days, and with more severe deficits, 90 days. (Stroke, 1994) It is also known that various other factors such as  post stroke fatigue, anxiety and depression can also influence how a patient performs in the early or even later weeks of treatment, and yet these are frequently overlooked, perhaps because they or more difficult to assess, in particular if there is a communication problem.

So, what can you do, if you, as a family member, feel that your loved one is still benefiting from rehabilitation, despite a  plan to discharge from treatment? An appeal is an option. This may sound scary to many family members, but it may represent the best opportunity to determine if in fact further therapy will be of benefit. Measuring  progress or improvement in response to treatment should be conducted using some standardized measures. Ask to review all of the therapy chart notes, and then request a meeting with one or several of the therapists and rehabilitation director. If the therapy team is not willing to extend treatment, a written Notice of Medicare Provider Non-Coverage (NOMPNC) form must be provided at least two days before the anticipated discharge , and you, as a family member should be given further guidance as to how to proceed.

"This is all so overwhelming. I consider myself a petty bright person, but this make me feel so inadequate,"  my cousin stated. I tried to re-assure her. It was not her, rather, the system , which sadly is designed to make us ALL feel that way. It is a daunting task for most people to navigate their way through the health care system , where care is now largely guided by payment. But, your insights, your intimate knowledge abut your family member and your observations about their response to therapy is all important.

I am not disregarding the fact that some times, an injury to the brain is so significant that further recovery of a specific motor or language function will never be anywhere near normal level. Nor am I disputing the fact that there is always a time when formal therapy must come to an end and strategies for stimulating further improvement in function,taught and transferred to family members or care personnel. But, it is the word, "plateau" I reject.  A word I have often thought had more to do with an individual therapist's own lack of creativity or skill set than the patient's abilities.

I am not sure that it is entirely possible for any of us as living and breathing human beings to "plateau" in life. The very word implies that life becomes flat. For my cousin, the word and this week represents the anxiety and fear that most family members must feel and face when they truly realize that recovery is a long process and that they are now the advocates for continued care.

A resource for families is the Stroke Connection. It is a free publication of the American Heart Association, and its stories and information provide encouragement and hope. You can find them on Facebook, visit their website, or call: 1-888-4-STROKE